1. Better Medication History Taking: The Way to Improve Medication Reconciliation Ed Tessier, Pharm.D., M.P.H., B.C.P.S. 1, 2 Elizabeth A. Henneman, Ph.D., R.N. 2, 3 Mark Heelon, Pharm.D. 3 Karen Plotkin, Ph.D., R.N. 2, 3 Brian Nathanson, Ph.D. 4 Supported by a grant from the American Society of Health-System Pharmacists Foundation 1 Baystate Franklin Medical Center, Greenfield, MA 2 University of Massachusetts Amherst School of Nursing 3 Baystate Medical Center, Springfield, MA 4 OptiStatim, LLC, Longmeadow, MA

2. Learning Objectives Discuss the effect of a collaborative nurse- pharmacist intervention on obtaining accurate medication and allergy histories. Identify drug categories frequently missed when obtaining a medication history. Identify factors which can improve the effectiveness of medication history taking by nurses.

3. Outline The Problem –Medication History Taking Inadequate. What We Did –Developed tool for nurses to improve medication history taking. –Trialed tool in controlled environment. –Trialed tool in clinical setting. What We Learned

4. Medication Reconciliation – The Lived Experience

6. Medication Reconciliation process is highly dependent on obtaining an accurate medication history

7. Adapted from: Tam VC. Knowles SR. Cornish PL. Fine N. Marchesano R. Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. Canadian Medical Association Journal. 173(5):510-5, 2005 Aug 30. Extent of Inaccurate Medication Histories

8. Our Charge

9. Primary Study Objective Evaluate the effectiveness of a collaborative nurse-pharmacist intervention in decreasing medication errors in both academic and acute care settings.

10. Study Sites University of Massachusetts Amherst School of Nursing –Undergraduate and Graduate Programs Baystate Medical Center, Springfield MA –653-bed academic teaching hospital Baystate Franklin Medical Center, Greenfield MA –93-bed acute care community hospital.

11. Nurse-Pharmacist Intervention Requirements Nurse Friendly Ability to Integrate into Nursing Practice Resource Neutral Transferable Across Settings Ability to Integrate in Nursing Education

12. What We Did

13. Tool Development Peer Reviewed by Nurses and Pharmacists

14. Medication History Taking Template Version 3.0 1. GET THE BASICS: Demographics - First/last name, date of birth Allergies – Drugs/foods; nature of reaction Diagnoses - Reason for admit/visit; other diagnoses Prescribers – Primary and Specialists

15. 2. BUILD THE LIST Do you have your meds/list of meds with you? 2A. LIST REVIEW Last updated? What other medications do you take?

16. 2B. SYSTEM REVIEW Do you take any medicines for: Neuro: Seizures? Headache? Psych: Sadness? Anxiety? Sleep? EENT: Allergies? Your Eyes? Pulm: Breathing? Inhalers? CV: Your Heart? Blood Pressure? Endo: Diabetes? Thyroid? GI: Your Stomach? Bowels? GU: Contraception? Your Bladder? Treatments for Erectile Dysfunction? Skel/Musc: Your Bones? Joints? Infection: Antibiotics? Derm: Topicals? Analgesics? Pain or Discomfort?

17. 3. WHAT’S MISSING? Antibiotics: treatments for HIV, TB? Other infections? Cardiac Drugs: antidysrhythmics, antihypertensives, cholesterol lowering? Clots: anything to prevent clots? warfarin(Coumadin®), enoxaparin (Lovanox®), aspirin, clopidogrel (Plavix®)? Corticosteroids: prednisone, hydrocortisone? Diabetes Drugs: insulin? oral agents? Electrolytes: potassium, calcium supplements Immunosuppressant Drugs: to prevent organ rejection or treat MS, arthritis, psoriasis, Crohn’s? Less Than Daily: drugs given irregularly (patches, injections at MD office)? MAOI’s: monoamine oxidase inhibitors? (Nardil®, Parnate®, linezolid - Zyvox®) Natural: herbal/vitamins, over the counter? Opioids: morphine (MS Contin®), methadone, fentanyl (Duragesic®), oxycodone (Percocet®, Oxycontin®)? Recreational Drugs: any “street drugs”, use drugs recreationally, smoking, alcohol? Seizures: drugs to prevent seizures

18. 4. PROBE FOR MORE For medications/conditions with incomplete information consider one or more of the following: Who ordered the medication? What dose? When did you last take it? Where do you get your medications? Why do you take it? Tell me about missed doses in the past week. What problems do you have with your medications?

19. 5. FINAL CHECK Is there anything else you would like to tell me about your medications that I have not asked?

20. 6. ADDRESS ASAP: Allergy Conflicts Antibiotics: HIV, TB, other Anticoagulants: heparins, warfarin Anticonvulsants: phenytoin, carbamazepine Antidiabetics: insulin, oral agents Antidysrhythmics: amiodarone, procainamide Corticosteroids: prednisone, dexamethasone Duplicate Medications: orders for lisinopril and enalapril total acetaminophen dose/24hrs not over 4000mg Immunosuppressant/Transplant Drugs: cyclosporin, mycophenalate MAOI’s: Nardil®, Parnate®, Zyvox® Opioids: morphine, methadone, street drugs

21. Trial in Controlled Environment 16 RN students 4 trained actors/ faculty played scripted standardized roles as mock patients each with medication list

22. Trial in Controlled Environment 16 Senior RN Students Informed Consent INTERVENTION 7 Students CONTROL 9 Students Randomization Training+Tool Med History With Mock Patient Assessment Of Accuracy Training+Tool Med History With Mock Patient Assessment Of Accuracy

23. Results of Trial in Controlled Environment * p < 0.01 using a two sample t-test for proportions *

24. Trial in Clinical Setting The tool and educational plan implemented on 4 nursing units: –2 at a community hospital –2 at a large tertiary care center Education: –Unit poster campaign –One on one sessions with nurses –Nurse “Kit”: Laminated Tool with Top 100 drugs Brand/Generic on back. Slides/Handouts

25. Outcome # 1: M edication Events METHODS Review of all spontaneously reported medication events on each unit for: Initial review by clinical pharmacist, secondary independent review by clinical nurse and by second clinical pharmacist. –Subset 1: All events. –Subset 2: All events related to med history taking. –Subset 3: All allergy events related to med history taking. Pre-Intervention 3 Month Period Intervention 1 Month Period Post-Intervention 3 Month Period

26. Outcome # 1: Spontaneously Reported Medication Events Rates All Spontaneously Reported Medication Events: Community Hospital – Lower POST over PRE: p = 0.181 Large Teaching Hospital – Similar POST over PRE: p = 0.826 Rates Events Related to Med History Taking: Community Hospital - Lower POST over PRE: p = 0.204 Large Teaching Hospital - Similar POST over PRE: p = 1.00 Rates Events Involving Allergies and Med Histories: Community Hospital - PRE vs. POST: no documented events Large Teaching Hospital - PRE vs. POST: no documented events All tests were either Chi Square or Fisher's Exact (Fisher's Exact were used when a count was < 3)

27. Outcome # 2: Medication Discrepancies PATIENT SELECTION Pre-Intervention 15 Days Immediately Prior Intervention 1 Month Period Post-Intervention 15 Days Immediately Post Intervention 50 Consecutive Admissions Randomized to 25 to ensure a greater variety of caregivers 50 Consecutive Admissions For Each of the Four Intervention Units: Randomized to 25 to ensure a greater variety of caregivers

28. Outcome # 2: Medication Discrepancies Alignment of Medication Orders at 3 Points of the Electronic Medical Record Electronic History And Physical Computerized Medication Orders During Admission Electronic Discharge Summary Elements Collected: Medications Allergies Date/Time Clinical Status MD Medications Allergies Date/Time Medications Allergies Date/Time Clinical Status Other Elements Collected: Demographics Site of Patient Prior to Admission

29. Categorization of Discrepancies MINOR DELAY (BEYOND 48HRS) Time between admission and POE or first dose exceeded 48 hours – likely benign implications (e.g. multivitamin delay ) IMPORTANT DELAY (BEYOND 48 HRS) Time between admission and POE or first dose exceeded 48 hours – potential clinically important implications (e.g. cardiovascular, anti-diabetic, corticosteroid delay) MINOR OMIT FOR HOSP. STAY Drug omitted during hospitalization – likely benign implications (e.g. multivitamin omit) IMPORTANT OMIT FOR HOSPITAL STAY Drug omitted during hospitalization – potential clinically important implications (e.g. cardiovascular, anti-diabetic, corticosteroid omit) MINOR OMIT IN DISCH. SUMMARY Drug omitted in discharge summary – likely benign implications (e.g. multivitamin omit) IMPORTANT OMIT IN DISCHARGE SUMMARY Drug omitted in discharge summary – potential clinically important implications (e.g. cardiovascular, anti-diabetic, corticosteroid omit)

30. Outcome # 2: Medication Discrepancies IMPLEMENTATION Electronic History And Physical Computerized Medication Orders During Admission Electronic Discharge Summary For Small Community Hospital: All Data Elements Available Electronically Electronic History And Physical Computerized Medication Orders During Admission Electronic Discharge Summary For Large Academic Teaching Hospital: H&P Not Available Electronically.

31. Outcome # 2: Medication Discrepancies RESULTS - Community Hospital Demographics of Pre vs. Post Intervention Similar Gender did not differ: PRE Female = 46.2% POST Female = 53.9% P-value = 0.423 ProviderPREPOST Hospitalist35 (71.4%)33 (66.0%) General Medical (Non- Hospitalist)8 (16.3%)8 (16.0%) Surgeon5 (10.2%)9 (18.0%) Obstetric1 (2.0%)0 (0%) Age did not differ: PRE: Mean(SD) = 68.1 (18.9) POST: Mean(SD) = 69.3 (18.4) P-value = 0.756 Providers did not differ: Fisher’s Exact P-value = 0.623, 1 missing value in the Pre-Intervention group

32. Outcome # 2: Medication Discrepancies RESULTS - Community Hospital Prior Location did not differ statistically Observation: –Trend toward more complex patients in PRE vs POST? Fisher’s Exact: P-value = 0.083 LocationPREPOST Home37 (74%)45 (90%) Nursing Home 9 (18%)4 (8%) Group Home 1 (2%)0 (0%) Hospital2 (4%)0 (0%) Rest Home 0 (0%)1 (1%) Other1 (2%)0 (0%)

33. Similar but Statistically Smaller Post Intervention (p<0.05) Outcome # 2: Number of Drugs/Patient RESULTS – Community Hospital

34. Outcome # 2: Rates of Discrepancies per Patient PRE Mean (SD) [No Discrepancies] POST Mean (SD) [No Discrepancies] P-value MINOR DELAY (BEYOND 48HRS) 0.14 (0.5) [45/50] 0.14 (0.64) [47/50] 0.461 IMPORTANT DELAY (BEYOND 48 HRS) 0.22 (0.62) [43/50] 0.20 (0.57) [43/50] 1.000 MINOR OMIT FOR HOSP. STAY 1.10 (1.25) [20/50] 0.60 (1.25) [35/50] 0.003 IMPORTANT OMIT FOR HOSPITAL STAY 0.63 (1.24) [33/49] 0.58 (1.36) [38/50] 0.339 MINOR OMIT IN DISCH. SUMMARY 0.28 (0.83) [42/50] 0.06 (0.24) [47/50] 0.110 IMPORTANT OMIT IN DISCHARGE SUMMARY 0.43 (0.71) [33/49] 0.18 (0.44) [42/50] 0.053

35. What the Intervention Did NOT Affect: Length of Stay: Allergy Discrepancies: VariablePREPOSTP-value LOS (Days)4.20 (5.09)4.02 (2.86)0.826 VariablePREPOSTP-value Allergy Discrepancy Rate0.14 (0.35)0.10 (0.3)0.541

36. Top 10 Drug Discrepancies These drugs represent 54.3% of all observed discrepancies 0102030 # of Discrepancies CARDIOVASCULAR: DIURETICS MISCELLANEOUS: COMPLEMENTARY/ALTERNATIVE THERAPY CARDIOVASCULAR: BETA ADRENERGIC BLOCKER BLOOD FORMATION: PLATELET AGGREGATION INHIBITORS GASTROINTESTINAL: ANTIULCER/ACID SUPPRESSION RESPIRATORY TRACT: BRONCHODILATORS HORMONES: ANTIDIABETIC AGENTS CNS:PSYCHOTROPICS:ANTIDEPRESSANTS GASTROINTESTINAL DRUGS: CARTHARTICS AND LAXATIVES VITAMINS/MINERALS 0102030 # of Discrepancies CARDIOVASCULAR: DIURETICS MISCELLANEOUS: COMPLEMENTARY/ALTERNATIVE THERAPY CARDIOVASCULAR: BETA ADRENERGIC BLOCKER BLOOD FORMATION: PLATELET AGGREGATION INHIBITORS GASTROINTESTINAL: ANTIULCER/ACID SUPPRESSION RESPIRATORY TRACT: BRONCHODILATORS HORMONES: ANTIDIABETIC AGENTS CNS:PSYCHOTROPICS:ANTIDEPRESSANTS GASTROINTESTINAL DRUGS: CARTHARTICS AND LAXATIVES VITAMINS/MINERALS

37. Goal: No medication discrepancies % Patients With NO Discrepancies: PRE: 20% (10/50) POST: 42% (21/50) p = 0.027

38. What We Learned

39. Lesson 1: Systematic Approach May Help Systematic approach for nurses in conducting medication histories associated with modest, but measurable improvement: – in controlled setting – in small community hospital setting

40. Lesson 2: Alignment of Goals and Responsibilities Success in controlled and smaller settings may be related to: – Motivated nurses who see medication history taking as important part of their job.

41. Lesson 3: Continuing/Ongoing Reinforcement Success in controlled and smaller settings may be related to: – Strong and positive one-on-one pharmacist/nurse relationships. – Process integrated into workflow. – Ongoing support for nurses.

42. Lesson 4: Missed Drugs Include Critical Agents Among top drugs in discrepancies: – Antidepressants – Drugs for Diabetes Mellitis – Bronchodilators – Antiplatelets – Bronchodilators – GI Cytoprotectants – Diuretics

43. Lesson 5: Catching Discrepancy Early May Reduce Risk at Discharge Intervention early was associated with trend toward fewer omissions at discharge.

44. Lesson 6: When in Doubt, Laminate It! Intrinsic “value” of tool appeared to improve when tool was: –Simplified –Logical –Visually Appealing –Provided Useful Information (including the top 100 brand/generic list) –Durable –Integrated into Workflow

45. Half of the modern drugs could well be thrown out of the window, except that the birds might eat them. Dr. Martin Henry Fischer

46. Now it’s your turn!

47. State of Med Rec in Rural New England What is your biggest obstacle? Who are the key players at your facility? –MD –Nurse –Pharmacist –Pharmacy Tech –Other What works? Any best practice to share? What doesn’t work? Anything else to share?